Perceptions and experience of rural older people in oral health management in China: a qualitative study

Background To explore the perceptions and experience of oral health management among rural older people in China. Methods Qualitative methodologies were used in this study. Face-to-face semi-structured interviews were conducted. Thirteen older adults in rural areas were purposively sampled at two metropolitan hospitals in Hunan, China. The data were transcribed and thematically analyzed, and MAXQDA software was used to assist with coding. Results Three overarching major themes and ten sub‑themes capturing the perceptions and experience of oral health management among rural older people were identified. Three themes emerged from the thematic analysis: oral health cognitive bias, poor management behaviors, and limited oral health services. Oral health management as a whole is negative, oral health behaviors are poor, oral health service utilization is limited. Conclusions Based on these findings, there is great scope here for improving the current status of oral health for rural older people around awareness, behavior, and access. Oral health education, improved oral health services and primary oral health promotion are warranted.


Background
According to World Social Report 2023 [1], the global population of people aged 65 and over will be 761 million in 2021, a figure that will increase to 1.6 billion by 2050. the population aged 80 and over is growing even faster.To achieve a sustainable future, the rights and well-being of older people must be prioritized.According to China's seventh national census [2], by 2020, 18.70% of China's population will be aged 60 and over, and 13.50% of the population will be aged 65 and over.The oral health of older people is an important health issue in an aging society [3] and is closely linked to the quality of life and chronic diseases such as heart disease, diabetes, and Alzheimer's disease [4][5][6].
According to the 4th Fourth National Oral Health Survey (2015-2016), the caries rate of the 65-74 age group is 98.4% and the prevalence of periodontitis was 64.6%, especially in rural areas [7].To address the growing burden of oral care in aging societies, a special provision of oral health care to older people and integration of oral care with primary care will be required [8].Oral health management is a concept that encompasses oral function management, oral hygiene management, and oral care during oral cancer treatment [9][10][11].Studies have shown that oral health is associated with oral health management [12].However, available research shows that older people have poor oral health management.According to the 2015 China Health and Retirement Longitudinal Study (CHARLS), 28% of Chinese older adults have no remaining teeth, and only 19% had used dental care in the past year [13].Poor oral health was associated with a negative impact on the oral health-related quality of life of older adults [14].
At present, a vast majority of quantitative studies of oral health have been focused on oral health behaviors, oral health knowledge, and oral health service utilization among older populations [13,15].However, studies regarding the perceptions and oral health management experiences of older populations living in rural areas are lacking, despite high rates of oral health problems among them.In this context, qualitative methods are needed to capture a wide range of information that can provide insight into the target population.Exploring the oral health management of these rural older groups requires knowledge, perceptions, and beliefs about teeth, dental disease, and oral health, as well as their experiences of oral health management, which will help to explore their problems to provide a theoretical basis for subsequent research.

Study aims
This study sought to understand the perceptions and experiences of oral health management among rural older adults in China, mainly older adults in rural areas of Southwest China, especially in Hunan Province, so that it's clear that this is not necessarily generalizable.Hunan Province has 36 city districts, 19 countylevel cities, 60 counties, and 7 autonomous counties, totaling 122 county-level districts.The province has 418 streets, 1,133 towns, 308 townships, and 83 ethnic townships, totaling 1,942 township-level divisions [16].The interviewees for this study were all from two hospitals in Hunan Province, which is divided into administrative centers that are divided into local administrative units, including villages or cities.
The specific objectives were: 1. to understand the perceptions and experiences of rural older adults about oral health management.2. to understand the oral health knowledge, attitudes, and practices of rural older adults.

Study design
A descriptive qualitative design was adopted for this study, to achieve an in-depth understanding of the experience of oral health management in rural older adults.The protocol was reviewed and approved by the College of Nursing, Central South University, Nursing and Behavioral Medicine Research Ethics Review Committee (E202294).

Participants
The study was conducted at two metropolitan hospitals in Hunan, China.

Sampling strategy
A purposive sampling method was used.Patients participated in face-to-face semi-structured interviews conducted in a quiet meeting room in the hospital, at a time convenient for each participant.A total of 13 rural older people in two dental clinics of two hospitals from October to December 2022 were selected as interviewees for this study, of whom coding saturation was reached after 11 cases were interviewed, while 2 additional cases were added to reach meaningful saturation.

Data collection
All interviews were conducted by the lead researcher (RA), who is an experienced nurse and understanding researcher in oral health promotion and research, and received training in conducting the in-depth interview, semi-structured interviews, and qualitative data analysis in the school's postgraduate programs before conducting the interview, and the interviewer did not have any prior relationship with participants.The researcher first contacted the head of the hospital and the director of the nursing department to explain the main content of the study.After obtaining the consent of the hospital and the department, potential research subjects were recruited and informed of the purpose and content of the study and the interview method, in particular, the form of data collection, the principle of confidentiality, and the right of the interviewees to refuse to participate or to withdraw from the interview in the middle of the process were explained in detail, and informed consent was obtained from the research subjects for all interviews and they signed the research informed consent form.In addition, personal information was kept confidential during the transcription of the audio data.
We used face-to-face, semi-structured qualitative interviews to understand the experience of oral health management.After 2 pre-interviews, the investigator developed a brief schedule to guide interviews, then the schedule was used as a guide since the interviews were semi-structured.Interviews were conducted until data saturation was reached.All interviews were audio recorded, with interviews lasting approximately 30 min to one hour.Non-verbal information of the research subjects was recorded during the interviews to form interview notes, and interview notes were written at the end of the interviews to assist in data analysis.The final interview schedule was as below: 1. How do you feel about your oral health?Do you think oral health is important to maintain good health?2. What are your usual oral health habits?3. How did you obtain oral health knowledge?Do you know any oral health-related knowledge and methods? 4. What do you choose to do when you have oral discomfort?

Data analysis
Audio recordings were professionally transcribed verbatim and de-identified before analysis.The data from the audio recording was transcribed within 24 h, and transcriptions were randomly reviewed for accuracy by the other authors.To maintain participant confidentiality, participant names were substituted by codes.MAX-QDA software was used to assist with coding [17].After each transcript was read for familiarity, the data was reviewed, coded, and indexed by the three authors based on grounded theory [18].Participants' transcripts were openly coded to derive keywords, and then common issues and themes between participants were identified.Initial coding of the transcripts was performed while reading the transcripts line by line.Initial codes were then modified by combination or deletion.Terms were developed from the codes on the basis of the research objectives of the study.Finally, the qualitative research report was prepared through the integration of the findings from the in-depth interviews.Axial coding enabled the development of major themes and categories, followed by selective coding.Throughout the data collection and analysis process, the three authors met regularly to discuss the themes emerging from the data and participated equally in the analysis process.This approach supports triangulation that aims to reduce researcher bias and increase reliability and validity [19].To verify the thoroughness and reliability of this study, the consolidated criteria for reporting qualitative research (COREQ) were examined [20].

Participant characteristics
Thirteen rural older people from two dental clinics participated in the study, after which the data reached saturation.Of the thirteen participants in this study, 6 (47%) were male and 7 (53%) were female, with the mean age being 69 years.The mean duration of the interview was 37 min (range: 32-58).The interviewees were mainly from the rural areas of Changsha, Xiangtan and Yueyang cities.The socio-demographic and oral health status of the participants are shown in Table 1.

Findings
From the diverse experiences of participants, we identified three main aspects about the perceptions and experience of oral health management among rural older people.The main findings are summarized in Table 2 below.

Oral health cognitive bias Insufficient emphasis and weak perception of needs
Many older individuals residing in rural areas tend to place less emphasis on oral health, primarily as a result of limited awareness and knowledge regarding oral health care.

A4: "If you ask me if my mouth is healthy, my thought is that I can eat it, and that's fine." A13: "It's fine if you can eat, alas, at this age, you still need dental care." A2: "It's normal for your teeth to fail as you get older, it's not a serious illness, don't worry about it." A9: "Some people are so particular that they brush their teeth 3 times a day, so I say brush your teeth if you've had enough."
Some older people in rural areas have negative attitudes such as helplessness and an old-age mentality, further reducing the perceived need for oral health.
A10: "It (the tooth) has its problems, there's no way to tell, it's not something that people can change."A8: "When you get older, you're going to die (laughs), it's not worthwhile (to see a dentist)."

Lack of awareness of negative impacts
The majority of older people in rural areas are not sufficiently aware of the negative effects of oral conditions, do not pay attention to and are not alert to uncomfortable symptoms in their teeth, and know little about diseases such as periodontitis and dental caries.They often perceive bleeding and painful gums as commonplace issues rather than symptoms of a disease, and lack a comprehensive understanding of the potential.
A1: "I've never been to the dentist, I don't go to the dentist if it's just a sore (tooth), (laughs) country people, it's okay."A4: "When my (gums) are swollen, I, for one, don't take medicine, I just stay up for a few days and I'm fine."A5: "When it hurts, sometimes it hurts for 2 days and then it doesn't hurt anymore, so forget it."A6: "My gums bleed, sometimes they bleed when I brush my teeth, it happens a lot and I don't take it seriously."A8: "Do you need to treat bleeding teeth even if you brush them?(Surprised)" A11: "I feel that many people have worm teeth (tooth decay), so I don't take it seriously."

One-sided understanding of information
Most rural older people's understanding of oral health comes from their older persons, hearsay, or their own experience, and is somewhat one-sided, which also leads to misconceptions about oral health among rural older people.
A6: "toothache have because that toothache is not a disease, the older are saying so, they also feel.I don't think (dental cleaning) is much necessary, some people go and wash and get it, and often things happen."A13: "I've heard that scaling can make the gaps in your teeth bigger, so that's not good."A9: "I haven't heard of scaling, I haven't paid attention to it, I'm not sure."A12: "Last time the doctor said he suggested I go for a cleaning and said it would make my teeth cleaner, but I haven't done it before and I don't know what it's like, so I don't want to go."A4: "Do you need to treat bleeding teeth even if you brush them?(Surprised)" A3 "I feel that many people have wormy teeth (cavities) and don't take it seriously."

Poor management behaviors Limited access to knowledge
The results of the interviews revealed that most rural older people have a low level of education, which to some extent limits their understanding of oral health information.
A1: "There are times when I can't read, I can't read, I'm not literate, I'm not cultured." Further, their vision and hearing deteriorate as they age, affecting the uptake and use of information.
A6: "The pamphlets issued by this hospital, and the information boards on the wall, I can't read or understand.A7: "I'm too old, my ears are not good, and I can't hear anything the doctor asks me." At the same time, many older people in rural areas do not take an active interest in their oral health, and most are forced to visit the dentist only when their symptoms are more serious.
A3: "The main thing is that this time the toothache is so bad that I can't sleep at night, and this side is swollen, so I can't help it." It was also felt that they were unable to access and identify information that would be useful to them.
A2: "Young people can play with their phones, we can't do anything."A7: "Don't know where to ask for information, don't know how to go to the dentist."A11: "We are usually just busy working and no one talks about these things.And I don't know where to find out about these things."A13: "My children tell me it's good to brush my teeth more often and my teeth more often, that's all I know."

Poor oral health habits
Some older individuals in rural areas have not established optimal oral hygiene practices exhibiting behaviors such as infrequent brushing, irregular brushing, and utilizing an incorrect horizontal brushing technique.Not have established optimal oral hygiene practices, exhibiting behaviors such as infrequent brushing, irregular brushing, and utilizing an incorrect horizontal brushing technique.
A1: "Sometimes I can't find my toothbrush and I don't brush my teeth for days."A6: "Usually get up in the morning and brush once, rarely at night."A12: "I go to bed after eating and I don't want to brush my teeth."A8: "I brush my teeth like this (gestures sideways), I always brush my teeth like this." A3 and A12: "I brush my teeth once in the morning."A9: "I brush (my teeth) sometimes and sometimes I don't."A5: "I've never brushed my teeth for the second time since I was a little girl."A9: "Sometimes my gums bleed when I brush my teeth, so I don't take it too seriously."I know very little about dental care products such as mouthwash and dental floss.

A13: "Usually I just rinse my mouth with water at most, I haven't used it, and I haven't heard of any special mouthwash."
They know little about dental care products such as mouthwash and dental floss.
A8: "The most I usually do is rinse my mouth with water, I've never used it, and I've never heard of any special mouthwash."A9: "My doctor advised me to floss, but I don't know how to use it and sometimes it used to make my gums bleed, so I stopped using it." A few proportions of rural older people have good oral health behaviors and can adhere to habits such as brushing their teeth and rinsing their mouth every morning and evening and reducing their intake of sweets.
A4 and A11 both mentioned, "Brush once in the morning and once in the evening."A5 and A3: "Try to eat fewer sweets."A8:" I know I can't chew betel nut, it's not good for my health and I've given it up." At the same time, some older people in rural areas are active and receptive to suggestions from family members to improve their oral health.

Delayed or impeded access to care
Even though some older people are aware of oralhealth concerns, they still harbor various reservations about visiting the dentist, including financial constraints, time constraints, transportation issues, fear of the unknown, among others.

Limited access to oral health services Poor accessibility to oral health services
Rural regions in China are characterized by relative underdevelopment and larger geographical expanses compared to urban areas, leading to a broader service area for oral health resources and a scarcity of public healthcare facilities and dental specialists.Consequently, there is inadequate accessibility to oral healthcare services, posing challenges for older individuals in rural areas seeking medical assistance.
A11: "It's far from home, it's a long drive, and I have to check the nucleic acid tests everywhere, and the processes in the hospital are troublesome."A5: "I didn't come to the dentist because I had a bad toothache this time and I couldn't stand it."As A10 repeatedly mentions, "There were no good doctors (when I was young), medicine was poor at that time, so I never went to the dentist.There were no hospitals at that time." At the same time, rural older people generally work as farmers at home, with limited economic income and no pension after old age, and poor economic conditions.Dental hospitals have not yet been included in the universal health insurance, and the high cost of treatment has also caused the inaccessibility of medical services, making rural older people more likely to choose to give up or go to some small clinics with limited levels of consultation and treatment, which affects the treatment and rehabilitation of oral diseases.
A3: "So I don't want to get (a denture), some people want thousands of dollars for teeth, some want tens of thousands for a mouthful.It's expensive in that hospital."A9: "I heard my child say that the last time he had his teeth cleaned it cost 38 yuan (RMB), and when I asked here (at the village clinic), it cost 88 yuan (RMB), which is more expensive than in the city, so I forgot about it."A5: "(Pause) One thing is, when you go to the hospital, they all ask for money, they ask for this and that."

Poor consultation experience
Rural areas face a scarcity of dental specialists, low professional standards among primary care physicians, inadequate dental treatment facilities, outdated treatment methods, and relatively deficient prevention and treatment services.Additionally, the coordination between dental clinics and hospitals is suboptimal, and the existing oral health resources are insufficient to address the oral health needs of residents.
A2: "What kind of good dental hospital is there in the countryside, many instruments are not available."A4: "The local doctor said I need dental implants here, but said he had limited conditions there and told me it was better to come to a large hospital." Furthermore, most rural older people have a poor experience in hospital dental clinics, with a cumbersome consultation process and long waiting times.
A11: "It's too far from home, it's impossible to come here normally, and the traffic is inconvenient."A9: "I've never been here before, it's hard to find and I can't read the map."A5: "It says you have to book in advance, but I don't know how to do that, I don't know anything and no one will teach me."A2: "Firstly, the traffic is not convenient, secondly, in the hospital, the process is complicated in all aspects, and the process is complicated and not adaptable.It has to check this way and that way, the process is complicated."A7: "I had my teeth extracted this time, and it said that there were 3 decayed teeth (caries) at the back, and they couldn't be extracted together, so I had to come back every once in a while, to have them extracted, which was troublesome."A10: "(The hospital) is not good, it's too troublesome, you can't see it all at once, after going there, you go to get it done today, and then you go to get it done again after 3 days, there is not so much time."

Lack of trust in the doctor-patient relationship
The lack of effective communication between rural older individuals and dentists has eroded trust in healthcare providers, leading to misunderstandings about treatment and unmet medical needs among this demographic.

Inadequate social security support
Currently, China's national health insurance excludes oral health care, despite many older individuals lacking multiple teeth and facing substantial treatment costs.The high expenses associated with procedures like restorative dentistry and dental implants, coupled with the absence of insurance coverage, significantly diminish individuals' willingness to seek oral health care and treatment.. A1: "It costs a lot of money for one visit."A2: "The doctor said that I have several cavities (tooth decay) and that I need to have my teeth extracted, which is very expensive and I don't have that much money."A5: "Last time, the doctor suggested I have a dental implant, but it was too expensive and not reimbursable, so I didn't want to have a dental implant (bitter smile)" A9: "I thought that's it, why spend so much money, I can eat anyway, I don't want to spend so much money again."

Discussion
The findings of this study suggest that rural older adults encounter challenges in effective oral health management, exhibit inadequate oral health awareness, and demonstrate suboptimal oral health behaviors, indicating the necessity for implementing strategies to enhance the oral health management capabilities of rural older adults.

Awareness of oral health among rural older people needs to be improved
The results of this study show that the awareness of oral health among rural older people needs to be improved, mainly in terms of a lack of awareness of the importance of oral health, a lack of knowledge of negative effects, and a partial understanding of information.Many studies have also shown that oral health services in China are characterized by more illnesses and fewer consultations [7,21] and that most patients with oral diseases do not pay enough attention to oral health issues and choose to seek medical attention only when oral problems cause functional limitations and have the greatest impact on their lives [22].This may be related to the low level of oral health awareness, lower educational attainment, and poor economic conditions of rural older adults.In line with prior reports on rural populations in Thailand, most participants could not identify oral health problems and placed a low value on oral health [23].A Swedish study of interviews from short-term care units also showed that some older people did not find it worthwhile to pay for a visit to the dentist [24].However, they are more concerned about their oral health and have better oral health care behaviors.In contrast, older people in the Netherlands who attend community dental clinics are relatively healthy, have a high socioeconomic status, and are better educated [25].The orally healthy older group is more concerned and focused on oral health, and highlight the important roles of their internal resources, dental professionals, family and society in supporting and reinforcing lifelong oral health [26].
In addition, this study found that rural older people's knowledge of oral health is more about the importance of teeth to their diet, but less about the links between oral health and general health and related chronic diseases [3], though there has been a great deal of research showing that oral disease is closely linked to several chronic diseases [27,28].Currently, many citizens in China are not aware of the importance of oral public health, and there is a strong preference for treatment over prevention [29], and a lack of a comprehensive strategy for the prevention and control of oral diseases.Even though most healthcare providers consider oral health to be important, people's basic oral care needs are largely unmet.Besides, providing dental services to older adults might be challenging because of physical and cognitive decline [30].Therefore, it is recommended that the relevant health management authorities should formulate a comprehensive oral disease prevention and control strategy, enhance training in geriatric dental curricula, and that policymakers in dental education, national dental organizations, and government agencies adopt policies that support the integration of oral health into overall health through robust reimbursement mechanisms, including dental benefits in Medicare.In order to enhance oral health practices and raise oral health awareness, communitybased oral health measures are required [15].

Oral management behavior of rural older individuals needs to be improved
The findings of this study revealed that the overall oral management behavior of the rural older is poor, mainly reflected in poor oral health behaviors.There are still many misconceptions about basic oral health habits such as brushing teeth once a day, brushing teeth horizontally, and not caring about bleeding gums when brushing teeth.Most older individuals do not know how to rinse with mouthwash, floss, or have regular oral check-ups, and most are forced to seek medical attention due to persistent discomfort and delays.A national oral health (2015-2016) survey in China showed that more than 90% of older adults have visited a dentist for treatment [31].According to the 4th Chinese national oral health survey, good oral hygiene practices and regular dental visits focusing on prevention are significantly associated with tooth retention [21].
However, the study also found that some older individuals were able to brush their teeth twice a day and actively listen to the advice of family members to try oral check-ups and cleanings, suggesting that the oral health behavior of rural older individuals may be influenced by their surroundings and family members.As most research has proven [32,33], a child's oral health is closely linked to their parents, and because of the influence of family familial ties [34], we, therefore, think that the oral health behaviors of the older could be in turn influenced by their children.A recent study focusing on a behavioral theory-based integrated family intervention to improve adolescent oral health through mobile messaging will be conducted to improve the oral health of adolescents [35].This suggests that home-based training may be more helpful in improving oral health behaviors when the health sector provides oral health training to older individuals.

Improving access to health care
Access to dental treatment can be difficult for older rural individuals who have low education levels and live in remote areas, which is consistent with most previous studies [21,36,37].In addition to physical limitations that limited access to dental services, there are broader psychological, sociological, and economic factors that frequently act as barriers.The main barrier is frequently perceived to be a lack of finances, which is similar to a study of stroke patients [38].Financial barriers include the direct cost of dental care and indirect costs like the cost of transportation.Worry, stress, and fear of treatment also have a significant impact on older adults' dental service utilization [39].In addition, oral health behavioral adherence in older individuals is affected by relationships between oral health practitioners and older adults.Inadequate support from medical staff, lack of effective patient-physician communication, and poorly developed oral health education will result in patients experiencing barriers to accessing dental care [40].According to a study of healthcare professionals' experiences with evaluating and providing dental care to older adults [41], the healthcare professionals themselves highlighted ignorance and their views as being particularly significant contributors.
In terms of the allocation of health care resources, the uneven distribution of resources for objective medical conditions has led to fewer oral health services for older individuals in rural areas.In China, rural areas are economically backward compared to urban areas, with few oral health resources, a lack of public health care facilities, and a shortage of dentistry specialists, making it difficult to meet the oral health needs of rural residents [42].
In terms of medical institutions and treatment levels.China's dental medical institutions are mainly divided into four categories: general hospital dentistry, dental specialist hospitals, chain dental clinics, and individual dental clinics [43].At present, the main body of the market is mainly individual dental clinics, individual clinics are generally dominated by doctors starting their businesses, with fewer professional doctor resources, average doctor skills, and uneven equipment and services, but due to a large number of shops and strong community, it is convenient to make appointments for consultation.Dental specialist hospitals have advantages in terms of experts, doctors' level, equipment, and services, but the distance is usually far and inconvenient.According to the 4th national oral health survey, the average percentage of residents visiting departments of dentistry in public hospitals is less than 10% [44].In the future, more attention should be paid to the equity of dental health resource allocation and service utilization, encouraging the improvement of oral health of individuals in areas with scarce medical resources, strengthening policy support for rural areas [45], promoting and regulating multipoint practice with a profit-oriented approach, increasing the introduction of talents, and promoting the reasonable flow of dental talent resources between urban and rural areas and between regions, to promote the benign development of the overall level of oral health in China [46].

Strengths and limitations
Our study addressed an important gap in the current literature.This study presents a real worldview of older people's perception of oral health and the experiences of oral management in China.However, this study is not without its limitations.Our sample size was relatively small regarding the majority of older individuals who did not attend hospitals or clinics were not interviewed due to lack of accessibility, besides, based on previous surveys and literature studies, this should make up a large proportion of the older adult population.Considering the physical strength and energy of older adults, most of the studies lasted more than half an hour, our interviews were no longer conducted after we got more saturated information from the interviewees, it can be considered to appropriately extend the duration of the interviews or increase the number of interviews without affecting the treatment and rest of the interviewees in the future studies, so as to enhance the trustworthiness of this study.Furthermore, many who participated had some difficulty with verbal communication with the interviewer, which may impact the quality of the data collected.Some patients may have felt obliged to participate; however, it was emphasized that participation was voluntary and non-participation would not affect the quality of nursing care.Since all interviews are in the hospitals, some participants may have provided responses that were less open.In addition, the findings are from two settings, and there is a potential for recall bias.Future work could consider recruiting participants not only in hospital outpatient clinics but also inwards, communities and village health clinics, etc.This might reveal more rural older people's views and experiences of oral health.

Conclusion
In summary.In this qualitative study, in-depth interviews were conducted with 13 rural older individuals to investigate and analyze their unique perceptions and experiences concerning oral health management based on their lived experiences.The participants faced challenges in engaging in effective oral health management, exhibited inadequate oral health perceptions and behaviors, and encountered limited access to oral health services.These findings contribute to a deeper understanding of the oral health challenges experienced by rural older individuals, highlighting the necessity for implementing effective strategies to enhance their oral health management.

Table 1
Key characteristics of participants (n = 13)

Table 2
Major themes and sub-themes